How to bridge the gap between the audiology clinic and the classroom? Educational audiologist Donna Fisher Smiley led a recent online chat tackling that question, and the Leader was there.
Jennifer Xenakes: Hi, Dr. Smiley. Two questions: Do you have any suggestions for collaborating with clinical audiologists when parents don't want the educational audiologist to contact them, even though we have a signed information release? [And] if making earmolds in school, does the educational audiologist bill insurance or Medicaid, or is the cost of materials built into school operating budget?
Donna Fisher Smiley: I think that is tough, Jennifer. When parents don't want us to communicate it makes it hard to really address the child's needs. I would start by trying to talk with the parents about how important his communication is between the managing side and the educational side. In response to question two: In Arkansas, we as school-based audiologists don't bill for those earmolds, etc. We go back to the managing audiologist and let them bill it, order it, etc. However, I suspect that many educational audiologists around the country do it differently- all depending on their setup.
Jane Woods: I'm frustrated, as clinical audiologists in my state seem to fit the child without considering FM [frequency modulation], whether in the school we will use it or not. We only have one audiologist for all 187,000 students. What have other states done to convince departments of education to increase the number of audiologists in the schools?
Smiley: I totally understand your frustration, Jane. We have spent a lot of time at Arkansas Children's Hospital, convincing our managing audiologists to consider FM (but not to over-consider it). One idea for working on that issue is to take opportunities at your state speech-hearing meetings to educate other audiologists about school-based needs. Also, begin to develop a relationship/conversation with administrators at your state level. My best suggestion for both groups is to offer to provide professional development related to working with students who are deaf or hard of hearing, and as you do that educate managing audiologists and educational administrators about what you need.
Gretchen Casebeer: What do you mean by "over-consider?"
Smiley: Sometimes I find that audiologists want to recommend FM for everything. But we need to consider many issues related to the specific child. For example, a child with a unilateral hearing loss: Should we always recommend FM for this hearing loss? I don't think so. I think we must consider several factors. For example, in what type of classroom setting is the child participating? If it is self-contained, the application for the use of personal FM would be very different-and may not be needed as much-than if the child is in a regular ed class with 25 other students. Does that help?
Catherine Mace: Is there a website you can recommend that provides hearing loss simulation, so we can better educate teachers and school staff?
Smiley: In my presentation, I mentioned Dr. Karen Anderson's website. If you haven't looked at this, it is a must. She has some great audio recordings on her website, as well as great resources for use in schools. Also, the Better Hearing Institute has a website with simulation. I had an experience where I shared the BHI website with some teachers. The most impactful item was when they figured out that the child they work with can't hear birds sing. It reached them at an emotional level that all of my "talking" wasn't getting to effectively.
Stacy Olver: Regarding [Jane Woods' question, above], I'm wondering about educating the teachers and speech-language pathologists to advocate with the educational audiologist for FM. Has this been done?
Smiley: We audiologists need others to advocate along with us for anything that we do. This includes the use of personal FM systems. I believe on Karen Anderson's website (under the simulations) she has linked some sound files that simulate listening to speech via a hearing aid versus listening to speech via an FM system or remote mic. I have used some of these. I receive more comments from SLPs and teachers about how listening to the difference in these sound files helped them really understand the difference in what a hearing aid might do in a classroom versus what a personal FM system will do for a child.
Laurynn Smith: You mentioned a co-op program in Iowa and Georgia. What is that exactly?
Smiley: It is my understanding that in Georgia they have "RESAs" [Regional Educational Service Agencies] and in Iowa they have "AEAs" [Area Education Agencies]-these are co-op programs that pull together professionals (like educational audiologists) who deal with the low-incidence issues. So in Iowa, for example, they "pool" their special types of professionals and then a given group or co-op is assigned to certain districts. In some cases, the districts pay-sometimes according to their number of students-for accessing the services. The catch is that a district can't say, "Hey, we don't have any students with hearing loss this year so we aren't going to participate in audiology." That won't work. I am not an expert on Iowa, Georgia or really any other state-but that is my understanding of how those RESAs and AEAs work in those states.
Ginette Perry: I wish to express my appreciation for the collaborative team approach you spoke so well about! In a state where we have a couple educational audiologists consulting with the entire state and mostly south of our region, it is helpful to SLPs to have audiologists who will provide consults via phone, e-mail, etc... All the audiologists we have consulted have been extremely helpful to us! Could you speak a little about how smartboard technology might interfere with FM systems? We have not encountered a problem with that, yet but I was curious as you mentioned that in your presentation.
Smiley: My experience has been that some smartboards have "soundfield" type speakers, etc. I have had a little bit of difficulty interfacing personal FM transmitters with some of the smartboards. I have had more success in interfacing personal FM transmitters with true soundfield systems so a teacher doesn't have to wear two mics. One other note: With a soundfield that uses infrared sound transmission, you have to be careful the teacher wearing the transmitter/mic doesn't stand in the light from the smartboard. It will interfere with the light (infrared) from the soundfield transmitter.
Ann Patton: It is very emotional when you realize what someone can't hear. I have a hearing loss myself and when I was fitted with hearing aids (newer technology), I cried because I actually heard sounds that I've never heard before. My husband was also hooked up so that he could find out-more or less-what it was that I couldn't hear. He was astonished.
Smiley: Ann, thank you for sharing your own experience. I think those of us who are audiologists, but who have typical hearing, sometimes forget the emotional nature of hearing loss. I need to be reminded every once in a while!
Rene Wehler: Do people have separate "standard report" forms they use for non-audiology folks (e.g., classroom teacher, SLP) versus what they send to audiologists and physicians? From a time perspective, it seems cumbersome, but from an effectiveness standpoint, it seems useful.
Smiley: Rene, you have hit on my soapbox in a way, so here goes: I say all the time to the "managing side of the house," please don't write "Hearing WNL, AU" and send that out to a school. But I do appreciate the time constraints for all of us; I think that we have to work harder to make the information we have to share more easily accessible and understandable by our patients, clients and students, and their families and school support teams.
Laurynn Smith: Where do we find state regulations for audiological information required for the school to have?
Smiley: First, start by looking at your Department of Education's website. I know in Arkansas, the Special Education Unit has a whole site devoted to rules and regulations. These types of documents should be publicly available. Dr. Cynthia Richburg and I did a study a few years ago (which I referenced in the presentation). One of the questions that we asked was related to whether or not a state defined hearing loss/deafness in more depth that the federal regulations do (IDEA). We were able to access most state-based information via the Internet. Just as an example, Arkansas goes on in regulation to define hearing loss (Pure tone average in the better ear; in Arkansas one of the "categories" for HI includes pure tone average of 20 dB or greater in the better ear, a definition for unilateral and a definition for High Freq). Great idea to know what your state has in regulation.
Tammy Croak: Who is the appropriate professional to do an acoustical analysis of a classroom? What are the components that should be part of this evaluation and report?
Smiley: I certainly think that an audiologist is an appropriate person to perform this type of evaluation. I think that the audiologist needs to have studied classroom acoustics to know what the standards are (there are ANSI standards out there for this). Some of the information that is important in this type of analysis would include the level of the teacher's voice in different parts of the classroom, the level of background noise and reverberation-although it is harder to measure and we don't have a lot of instrumentation that is affordable. I also think that an audiologist who understands the educational piece could do a classroom observation relative to a specific student. This should include analysis of seating arrangement, intensity of teacher's voice, level of background noise and sources of noise, and the presence of reverberant surfaces, etc.
Gretchen Casebeer: The "Educational Audiology Handbook" [by Cheryl DeConde Johnson and Jane B. Seaton] has a nifty form to fill in for your classroom measurements.
Smiley: The "Educational Audiology Handbook" is a must-have for school-based audiologists. It is a guide to live by. It has so many tools, such as classroom measurements, etc.
Michele Elkin: How can I educate clinical audiologists regarding specific recommendations for FM use and to encourage them to communicate with me prior to making those recommendations? I have experienced these recommendations but when functional listening evaluations are done and find no significant difference, parents feel I am not willing to provide a system for their child.
Smiley: Michele, you are experiencing what we have also. I go back to my thoughts about volunteering to present/talk to audiologists in your state about pediatric patients, such as close and distant, with FM/without FM, with noise/without noise. Bottom line: any opportunity you have to provide continuing education to your fellow audiologists, take it! Several years ago, I presented at our state speech-language-hearing association. We talked about, "Hey, these are things you might want to know before you see kids in your practice." After the presentation, one of the clinical audiologists who works for an ENT in South Arkansas came up to me and said, "I've been feeling bad and thinking that maybe I should go out and do something for the schools in my area, but after your presentation, I've decided I have no idea what to do out there. So I will leave that up to you all who have that skill set." But he has called us when he has a kid to ask if we can help him figure out what they need in terms of assistive technology. I think making yourself available as a resource for the managing audiologists who have patients in the schools you serve will go a long way for them.
Tammy Croak: How valuable-or not-would a sound level meter from a store like Radio Shack be in helping to answer some of the questions about classroom acoustics?
Smiley: Tammy, I think those sound level meters are great tools for us to have in our "toolkit." I think they are easy to use and at least get us in the ballpark for background noise levels or teacher's voice levels-I love them!
Rene Wehler: Regarding Michele Elkin's question: I know we used to have standard recommendations that we'd include in our reports. I believe one was: "Consider use of an FM system…" The purpose was to put it out there, but not say it was required. Do you think that still creates problems for the educational audiologist or school?
Smiley: I do think that "standard" recommendations such as "consider FM" can be a problem. What about in a school with no audiology services? Who is to consider this? I would love to see us be able to make a recommendation-or not-with some evidence to support why we think a child does or does not need an FM system. This is challenging, I know, and I think we are still working on figuring out (as a field) how to provide that evidence. But verification and validation measures do exist, and if we are going to dispense personal FM, then I think we have to do these types of measures. I think if we are going to recommend personal FM, then we might want to figure out who to follow up with at the school.
Rene Wehler: If there are no audiology services in the school, how will they know to even do an intervention regarding the possible benefit of an FM?
Smiley: That should be of great concern to all audiologists in a state. Who will see that FM is evaluated? If I dispense an FM, who will see that it works properly? (It isn't brain surgery, but it is complex at the least.) Rene has raised the biggest issue in terms of the future of school-based audiology: What do we do in places where students don't have access to these services? We need to work together to improve this situation. IDEA defines audiology as a related service; it should be available to all.